What medication class can be added to a patient with heart failure (HF) to reduce mortality, morbidity, and risk of HF readmission, given a recent HF exacerbation?

SGLT2 Inhibitors for Heart Failure Management After Recent Exacerbation

SGLT2 inhibitors should be added to the treatment regimen for PM to reduce mortality, morbidity, and heart failure readmission rates, as they have demonstrated significant cardiovascular benefits in patients with heart failure regardless of diabetes status. 1

Rationale for SGLT2 Inhibitors in Heart Failure

SGLT2 inhibitors have emerged as a crucial component of quadruple therapy for heart failure with reduced ejection fraction (HFrEF). The American College of Cardiology recommends combining SGLT2 inhibitors with:

• Beta-blockers
• Renin-angiotensin system inhibitors
• Mineralocorticoid receptor antagonists

This combination significantly reduces mortality and hospitalizations in patients with HFrEF 1.

Benefits of SGLT2 Inhibitors in Heart Failure

• Decrease heart failure hospitalizations and cardiovascular mortality
• Number needed to treat (NNT) of 22 to prevent one death over 36 months
• Beneficial effects independent of glycemic control
• Particularly valuable after a recent heart failure exacerbation

Recommended SGLT2 Inhibitor Options

• Dapagliflozin: 10 mg once daily
• Empagliflozin: 10 mg once daily

Alternative Option: Sacubitril/Valsartan (ARNI)

If SGLT2 inhibitors are contraindicated or not tolerated, sacubitril/valsartan is another excellent option:

• Indicated to reduce the risk of cardiovascular death and hospitalization for heart failure 2
• Recommended as a replacement for ACE inhibitors in patients who remain symptomatic despite optimal treatment 3
• Demonstrated significant reduction in cardiovascular mortality and heart failure hospitalization compared to enalapril 4, 5
• Starting dose: 49/51 mg twice daily, titrating to 97/103 mg twice daily as tolerated 2

Implementation Considerations

When adding an SGLT2 inhibitor:

1. Monitor for hypotension, especially if the patient is already on multiple antihypertensive medications
2. Assess renal function before initiation and periodically thereafter
3. Educate the patient about potential side effects, including genital mycotic infections and volume depletion
4. Consider temporary dose adjustments of diuretics if needed

Common Pitfalls to Avoid

• Underutilizing SGLT2 inhibitors due to concerns about their glucose-lowering effects in non-diabetic patients
• Failing to optimize all four pillars of heart failure therapy (beta-blockers, RAS inhibitors, MRAs, and SGLT2 inhibitors)
• Not monitoring for potential side effects such as hypotension or renal function changes
• Delaying initiation of SGLT2 inhibitors after a heart failure exacerbation

Monitoring Recommendations

• Regular assessment of renal function
• Monitoring for symptoms of hypotension
• Tracking heart failure symptoms and signs of fluid retention
• Evaluating for improvement in functional capacity

By adding an SGLT2 inhibitor to PM's regimen following her recent heart failure exacerbation, you can significantly reduce her risk of future hospitalizations and improve her mortality outcomes, addressing both her heart failure management and providing additional benefits for her diabetes control.